ABORTION remains a sensitive matter in most countries,
receiving considerable international attention not only as a public health
concern but also as an ethical/moral/religious issue. Public discussion on
abortion has either centred on declining sex ratios and sex selective
abortion or on the proliferation of clinics across urban India.
Unfortunately, there is much less public debate on abortion related
morbidity and mortality despite several national programmes and campaigns
for safe motherhood.

As Bela Ganatra points out in her study, ‘Abortion is
also a singularly difficult topic to research; even legal "abortion
seeking" remains a private, sensitive act with negative moral and
emotional connotations that sets it apart from other reproductive health
treatment seeking. It is not surprising then that much of available
literature in India focuses on the secondary analysis of official data or on
the study of easily accessible urban hospital populations.’1
Therefore, attempting a nationwide research study on quantitative and
qualitative aspects of abortion – from both the provider’s as well as
women’s perspective was not easy.

Given the volatile nature of this issue, especially in a
world where ethnic, religious and community identities have gained greater
legitimacy in politics, researchers and activists have shied away from
initiating a public debate on abortion. Some argue that this may push the
clock back and women will face a setback in reproductive rights. This
concern acquired a sense of urgency in light of the US government’s threat
to withdraw support for research on abortion and support to international
(including multilateral agencies like UNFPA) organizations that work on
abortion and related issues.

The post-ICPD Cairo (September 1994) conference period
created a new window of opportunity in India. The Government of India’s
decision in the post Cairo phase (1996) to introduce a more comprehensive
Reproductive and Child Health (RCH) programme in place of vertical safe
motherhood, child survival and family planning programmes gave women’s
health advocates an opportunity to re-establish the importance of a holistic
approach.

D

onors
supporting the government’s efforts (World Bank, European Community,
Swedish International Development Cooperation Agency, DANIDA and DFID)
highlight the importance of looking at abortion-related mortality and
morbidity as a part of the RCH package. This created a favourable climate in
the country to examine the issue from different dimensions and work towards
making abortion safe. In the last six years the Government of India and
various state governments too have attempted to develop district-specific
plans for RCH programmes. These efforts have been noteworthy and
administrators are trying to grapple with hitherto unexplored public policy
issues. It may be some years before the effort will bear fruit, but given
the present public policy climate in the country, the trend is positive.

The 2001 Census jolted the government and civil society
alike – an alarming decline in the juvenile sex ratio from 971 in 1981 to
945 in 1991 and 927 in 2001 made national as well as international
headlines. The release of provisional Census 2001 figures was followed by a
series of national as well as regional meetings to understand this alarming
trend and evolve policy instruments to reverse it. This led to a renewed
interest in enforcing The Prenatal Diagnostic Techniques (Regulation and
Prevention of Misuse) Act (PNDT Act) enacted in 1994 by the Government of
India for the regulation of the use of prenatal diagnostic techniques and
prevent its misuse for the purpose of prenatal sex determination leading to
female foeticide.

In the last 15 years women’s health advocates have
tried to draw the attention of policy-makers and administrators to a range
of issues related to abortion in order to improve the availability, safety
and use of services, including:

* abortion perceived as an extension of the government’s
population stabilization programme;

* tendency to use abortion as yet another means of family
planning;

* growing trend in many areas towards sex selective
abortion;

* inadequate safe abortion facilities within reach of the
majority of poor women in rural and urban areas;

* inadequacy of post-abortion family planning counselling
and services; and

* abortion not perceived as a women’s health issue
among policy-makers and service providers.

G

iven
the above trend in India, there was a feeling that it was an opportune time
to initiate a nationwide debate on abortion. While the climate was
favourable to initiate debate among key stakeholders, a lack of reliable
information, wide regional variations, rural-urban differences and a thin
research base made it difficult for policy-makers, administrators and women’s
health advocates to develop strategic interventions. There is little
dialogue between different stakeholders and it is not uncommon to see
registered service providers, unregistered/untrained practitioners, women’s
health advocates, population control lobby, public health advocates and
others working at cross-purposes.

To fill the gap in our understanding of the ground
reality with respect to induced abortion in India and to create
evidence-based body of knowledge, the Abortion Assessment Project – India
(AAP-I) was designed as a multicentric research study.

2
This study was designed in collaboration with the Ministry of Health and
Family Welfare, Government of India and funded jointly by Ford Foundation,
Rockefeller Foundation and MacArthur Foundation. The project was housed in
Cehat, Mumbai and HealthWatch, Jaipur. The main objectives of the project
were:

* review government policy towards abortion care,
availability of funds, its flow and policy/programme environment in the
country, including family planning and abortion care;

* assess and analyze abortion services, including
organization, management, facilities, technology, registration, training,
certification and utilization in the public and private sector;

* estimate the rate of abortion, resultant morbidity and
mortality and reasons for induced abortion.

A

t
the outset, it was acknowledged that abortion is not only a sensitive issue,
but that a vast number of service providers are not registered. Therefore,
gaining their confidence would be important. Given the prevalent political
and administrative climate in the country, certification/registration is
contentious; unregistered providers may not be willing to talk unless the
researchers ensure complete confidentiality. This necessitates that the
study adhere to strict ethical criteria and ensure confidentiality, crucial
not only to gain the confidence of service providers, but also create a
non-threatening environment for inquiry.

Researchers and social activists point out that given the
secrecy and often ‘shame’ associated with abortion, women do not speak
freely. However, if a local woman’s group or a heath worker has gained the
confidence of the community, women are more willing to talk about their
abortion experience. Therefore, the study did not rely on researchers alone,
but tried to work with social groups that have established a rapport with
women. We were aware of the need to design data/information gathering tools
to facilitate data collection in a gentle and non-judgemental manner.

A

technical advisory committee consisting of researchers, providers and
nominees of GOI and ICMR was constituted to guide and monitor the project.
All proposals, research protocols and ethical guidelines were reviewed and
approved by the TAC. The following stakeholders were represented in the TAC:3
Policy-makers and administrators who are involved in the decision-making
process related to medical standards for abortion care (MOHFW, GOI and ICMR);
medical community represented by FOGSI; family planning service providers (Parivar
Seva Sanstha); community-based organizations and women’s health advocates;
social science and medical researchers; and demographers and family planning
advocates (members of the population lobby).

T

he
TAC was of the unanimous view that AAP-I should adhere to strict ethical
guidelines. While medical research in India is normally undertaken within
the framework of Indian Council of Medical Research’s ethical guidelines,
this practice is not prevalent in social science research. The TAC was of
the view that this project should mark a departure and adopt a code of
ethics for research on abortion and related issues.

To this end, the TAC recommended formation of an Ethics
Committee to:

4
review all proposals and protocols from an ethics standpoint; provide
assistance and training on ethical aspects to IEC of partner institutions
and researchers whenever needed; monitor ethical concerns through review of
reports submitted by researchers and through field visits as and when
required; provide inputs on ethics in project workshops and meetings; and
address ethical dilemmas faced by researchers and act as a sounding board.

On commencement of the project, all the collaborating
institutions came together and agreed on a code of ethics to be followed
during the course of the study and in dissemination of study findings. Among
the important protocols agreed upon were informed consent, protecting the
identity of the respondent – abortion seekers as well as abortion care
providers, data to be presented only in a tabulated form, and narratives
used only after the identity of the respondent and his/her area is
camouflaged. An important decision taken was that the data collected through
this study would be available for use of researchers, women’s health
advocates, the government and any other stakeholder. To this end, tabulated
data and the reports will be made available on the Cehat website. A separate
budget provision was made to ensure the implementation of the code of ethics
developed by Cehat and discussed and finalized by the TAC.

G

iven
the prevailing situation of abortion services and the changing perception
and values of the community, the national assessment study covered not only
a wide geographic area but also tried to capture the various dimensions of
the problem. There are five dimensions to this study.

An overview paper on policy related issues, series of
working papers based on existing data/research; multi-centric facility
survey in six states, namely Rajasthan, Haryana, Kerala, Madhya Pradesh,
Mizoram and Orissa; qualitative studies on specific issues to compliment the
multicentric studies. A total of nine qualitative studies were commissioned;
community based studies (among other issues) to estimate abortion rate in
Maharashtra and Tamil Nadu; and dissemination and advocacy.

It was hoped that a five-pronged approach would capture
the complex situation as it obtains on the ground, provide policy-makers,
administrators and medical professionals valuable insights into abortion
care and help identify areas for public policy intervention and advocacy.

The project that commenced in August 2000 is now nearing
completion. Managing such a vast project with multiple partners was a
challenging experience. Multicentric and multi-stakeholder research is not
only about gathering and analyzing data, it is also about keeping a diverse
group together, managing people and managing the politics of different
agendas and people holding different views. The legitimacy of such an
ambitious project ultimately depends on its ability to carry people along
and keep them together.

Given that almost all the members of the two key project
management committees – TAC and ECG – are professionals with a tight
work schedule, bringing them together for meetings, ensuring that them
informed and keeping the government is kept in the loop was indeed an uphill
task. Equally, balancing the priorities of professional
researchers/academicians with that of social activists was not easy. Unlike
large national surveys like NHFS, many of our partners were not professional
researchers. Building the research capabilities of activist groups who were
partners in the qualitative studies demanded some handholding. As we are
reaching the end, we realize that it was not always possible to ensure good
quality reports – even though the qualitative information gathered was
fairly good.

Footnotes:

1. Bela Ganatra. ‘Abortion research in India: What we
know and what we need to know’, in Radhika Ramasubban and Shireen J.
Jejeebhoy (eds.) Women’s Reproductive Health in India. Rawat
Publications, Jaipur and New Delhi, 2000.

2. The study was designed in 1998-99 by a team led by
Vimala Ramachandran, then a visiting faculty at IIHMR, Jaipur. The late Dr.
Ruksekesh Maru, then Director, The Indian Institute of Health Management
Research, Jaipur (IIHMR) negotiated a planning grant with Michael Koenig of
Ford Foundation to prepare a proposal for an abortion assessment project
after consulting important stakeholders in India.